Saint John Xxiii Home

In the surveyor’s words

From the most serious findings on record at Saint John Xxiii Home, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Apr 25, 2024

  Based on review of facility policy, observations, and staff interviews, it was determined that the facility failed to maintain sanitary food service operations for one of one kitchens. Findings include: Review of facility policy entitled, Dish Machine Temperature Log, last reviewed 7/26/2023, revealed The dish machine temperature log should be completed to ensure proper temperatures are met before sending ware through dish machine. Documentation must include date, temperature of wash and final rinse and initials of the recorder at each mealtime. The temperature log also identified that the final rinse temperatures should be at least 165 degrees Fahrenheit (F) and up to 180 degrees F to ensure proper sanitization. Upon observation of the dish machine on 4/22/2024, at 1:05 p.m. […]

• No harm, potential for more than minimal, isolatedF641Mar 28, 2025

  Based on review of clinical records and the Minimum Data Set (MDS - federally mandated standardized assessment conducted at specific intervals to plan resident care), and staff interview, it was determined that the facility failed to ensure that the MDS assessment accurately reflected the status of one of 16 residents reviewed (Resident R2). Findings include: Review of MDS instructions for Section H Bladder and Bowel subsection H0300 Urinary Continence indicated that urinary continence is to be coded as not rated if during the seven-day look-back period the resident had an indwelling bladder catheter (tubing from the bladder to drain urine into the bag), condom catheter, ostomy, or no urine output for the entire seven days. […]

• No harm, potential for more than minimal, isolatedF695Mar 28, 2025

  Based on review of facility policy and clinical records, observations, and staff interview, it was determined that the facility failed to promote cleanliness and help prevent the spread of infection regarding respiratory care equipment for one of three residents reviewed (Resident R17). Findings include: Review of facility policy entitled Oxygen Administration dated 3/24/25, indicated to check and clean oxygen equipment at regular intervals. Resident R17's clinical record revealed an admitted [DATE], with diagnoses that included Atrial Fibrillation (A-Fib - irregular and often rapid heartbeat that can lead to stroke, heart failure, and other complications), anxiety (a condition that causes a person to be nervous, uneasy, or worried about something or someone), and high blood pressure. […]

• No harm, potential for more than minimal, isolatedF842Mar 28, 2025

  Based on review of facility policy and clinical records, and staff and resident interviews, it was determined that the facility failed to have complete and accurate documentation regarding indwelling catheter changes for one of two residents reviewed with an indwelling catheter (Resident R2). Findings include: Review of facility policy entitled Catheter Care dated 3/24/25, indicated under General Documentation Guidelines to document date, time, procedure, signature and title. And under General Infection Control Guidelines that all indwelling urinary catheters are to be changed every month unless otherwise ordered by the physician. […]

• No harm, potential for more than minimal, isolatedF758May 4, 2023

  Based on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to provide a clinical rationale for the continued use of a PRN (as needed) psychotropic (affecting the mind) medication beyond 14 days for one of five residents reviewed (Resident R1). Findings include: Review of a facility policy entitled, Psychotropic Medications dated 7/2022, indicated that PRN orders for psychotropic medications other than antipsychotic medications are limited to 14-day orders. The attending physician or prescriber may extend the order beyond 14 days if he/she believes the order is appropriate. […]